Please fill in the boxes and use the TAB key to move to each box.

Your Full Name
Email Address
Street Address
Apt./Unit
City
State
Zip
Home Phone Number
Work Phone Number
How would you like for us to respond to you	TelephoneEmailUS MailDoes Not Matter
What is the best time to reach you by telephone?	In the morningIn the afternoonIn the evening
Type of personal injury
Date you were injured
Where were you hurt?
Describe the accident that caused your injury as thoroughly as possible:
Who do you believe was at fault?
What he/she did wrong
Describe your injuries
Was this injury permanent or temporary?	Permanent Temporary
Have you contacted any other lawyer about your claim?	Yes No
Did the lawyer agree to represent you?	Yes No
Are you still being represented by this attorney?	Yes No
Are you seeking representation or a second opinion?	Representation Second opinion
Have you negotiated with any insurance company or any person involved in this claim?	Yes No
Have any medical, funeral bills or lost wages been paid for by any of the following:
Worker's Compensation:	Yes No
Medicare, Medicaid or any other government program?	Yes No
Employer health plan	Yes No
Private insurance	Yes No
Do you have any questions that you would like answered?
Is there any other information or instructions you would like to provide us with?
Would you like to arrange an interview?	Yes No
Verification:

* Law Offices of Roy L. Glass. (Hereafter identified as The Firm) provides this form for information purposes only. It is intended for use by those individuals and entities that may become clients of The Firm and have legitimate concerns of questions for the practice area of The Firm. This report is not a contract for representation with The Firm. To become a client and have The Firm represent your interest will require a written contract and Statement of Client's Rights to be signed by the client and The Firm.